• Title/Summary/Keyword: medical records

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The Development of Discharge Analysis Educational Program on NCS-Based for Medical Information Management (NCS 기반 의료정보관리를 위한 퇴원분석 교육프로그램 개발)

  • Choi, Joon-Young
    • The Journal of the Korea institute of electronic communication sciences
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    • v.12 no.5
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    • pp.957-964
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    • 2017
  • In this study, It developed a program to carry out the training courses for NCS based medical information management tasks and to can understand the practical working knowledge of learners. This program is an educational program that can generate medical information by analyzing data of medical records after generating and storing data of medical records. Because the contents of the medical records vary and there are quantitative differences in the medical records, the contents of the medical records can be summarized and stored in the discharge analysis program for the standard of educational data. The medical terminology DB, medical terminology related DB, medical care related DB by the NCS ability unit element can be constructed and managed using the program. The following are the contents that can be learned through operation of the program. first, it's can understand Medical information DB management regulations through understanding sturucture of database. Second, it can understand the structure and function of the diagnostic code and medical practice code that are input to the discharge analysis program. The diagnostic codes and medical practice codes entered in the discharge analysis program can be searched and analyzed by each fields. Third, It can be advance medical information management ability by inputting and extracting data and generating medical information. In this study, It developed program that Students can be obtained Knowledge of medical information management and improved management competency by generate and analyze medical record data using discharge analysis program.

Predictability of the completeness of medical recording of quality of care for inpatients (의무기록 완성도의 입원환자 진료적정성에 대한 예측도 평가)

  • Park, Un Je;Park, Eal Whan
    • Quality Improvement in Health Care
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    • v.3 no.2
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    • pp.60-68
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    • 1997
  • Background : Medical records are used to assess clinical performance of physicians and quality of care. The contents which are written in medical records are considered as the objective evidences to know what the doctors think about the patient's problems. But the problem to use medical records as the assessment tools is the incompleteness of medical recording. The purpose of this study is to know if the completeness of medical recording is correlated to quality of care for inpattients and it can predict physicians's quality of care. Method : 32 clinical physicians reviewed 200 patients' medical records who were selected randomly from the inpatients who were admitted to the university hospital during July, 1995 and June, 1996. The reviewers used the structured evaluation questionnaires which were composed of two part. One part evaluated the completeness of the medical recording and the other evaluating appropriateness of diagnosis and treatment processes. We summated the scores of each items and calculated percentile scores. Results : The mean percentile score of completeness of the medical recording was 67.9% in 1995 and 79.8% in 1996. The mean percentile score of appropriateness was 52.2% in 1995 and 69.5% in 1996. This change between 1995 and 1996 was statistically significant. In non-surgical patients, the percentile scores of the completeness and those of the appropriateness were correlated positively and this correlation was statistically significant(p<0.05). In surgical patients, the positve correlation between the completeness and the appropriateness was also statistically significant(p<0.05). Discussion : In conclusion, the completeness of medical recording is considered as the good predictor of the quality of care for inpatients.

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A Study about medical records in ${\ulcorner}$Gyojubuin-yangbang${\lrcorner}$ (${\ll}$교주부인양방(校注婦人良方)${\gg}$에 수재된 의무기록 의안(醫案)에 관한 연구)

  • Oh, Chang-Young;Kim, Ra-Young;Park, Young-Soo;Kim, Byoung-Hoe;Joh, Ho-Geun;Kim, Joong-Oh;Kim, Dong-Il
    • The Journal of Korean Obstetrics and Gynecology
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    • v.19 no.2
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    • pp.226-239
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    • 2006
  • Background : Medical records are documents in files which consist of all diagnostic studies and medical treatments patients had received while they were hospitalized or treated as outpatients. A doctor or medical team can use medical records as a data for diagnosis, treatment, and education. In traditional eastern asian medicine, medical reports have different forms and contents. The most important thing in medical reports of traditional eastern asian medicine was how to express practitioner's medical ideas. So it has a weak point, for example, it has poor information about patient and clinical process, which make some trouble to understand it. Methods and Results : We studied medical records in Gyojubuin-yangbang, a commentary book of Chen-zi-ming's Obstetrics and Gynecology textbook done by Xue-ji in Ming dynasty, China. This book consists of 10 parts; treatment of menstruation disorders and leukorrhea, general gynecology, treatment of infertility, education for fetus, diagnosis of fetus and gravida, treatment of general and obstetrical disease in gravida, care for delivery, postpartum care and treatment, and treatment of mass and inflammation. It has 546 medical records about women's disease that commonly believed as Xue-ji's case reports. They are all review articles and made during about 23 years from A.D 1523 to 1546. Most patients of Xue-ji's case reports were common people, this fact is different from that of case reports in Chen-zi-ming's Obstetrics and Gynecology textbook. Conclusion : Xue-ji was a very famous Ob&Gy doctor who was from Suzhou Jingsu province in China. He was born in A.D 1468, died in A.D 1588. He emphasize emotional factors in pathology and to tonify spleen and kidney. We think Xue-ji's medical records are good references for us to treat psychosomatic Ob&Gy disease and chronic women's disease.

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A Study on Clinical Records of King Hyeonjong's Queen, Queen Myeongseong, Focusing on Cases Recorded in the Seungjeongwon Ilgi (The Daily Records of Royal Secretariat of Joseon Dynasty 承政院日記) (현종 비 명성왕후의 복약 기록 연구 - 『승정원일기』의 의안을 중심으로 -)

  • Park, Jooyoung;Kug, Sooho;Kim, Namil;Cha, Wungseok
    • The Journal of Korean Medical History
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    • v.32 no.1
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    • pp.11-20
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    • 2019
  • Queen Myeongseong was the wife of King Hyeonjong, the 18th king of the Joseon Dynasty, and the mother of King Sukjong. The clinical records of Queen Myeongseong are summarized on the basis of the Seungjeongwon Ilgi (The Daily Records of Royal Secretariat of Joseon Dynasty 承政院日記) and reviewed through Donguibogam. Queen Myeongseong gave birth to one male and three female children in the time of the queen. She took Geumgaedangguihwan (金櫃當歸丸), Dalsaengsan (達生散), Antaeum (安胎飮) during her pregnancy and Gungguitang (芎歸湯) during postnatal care. Since 1669, chest tightness, sleeplessness, arm pain and numbness of arms had been appeared. Ondamtang (溫膽湯) and Dodamtang (導痰湯) were used but they were not effective. However, when her symptoms were regarded as a benign tumor due to cold and wetness, there was a difference in the use of Ohjuksan (五積散). In 1683, when king Sukjong was caught in a smallpox, she took care of him. She exorcised in the middle of winter to pray for her son's recovery, and died of the flu.

Study on Jong-jun Lee's Medical Records in Sinsuntaeeuljagumdan ("신선태을자금단(神仙太乙紫金丹)"에 수록된 이종준(李宗準) 의안(醫案)에 대한 연구)

  • Kim, Jae-Eun;Choi, Dall-Yeong;Jeong, Han-Sol;Shin, Hyun-Jong;Shin, Sang-Woo;Ha, Ki-Tae
    • Journal of Physiology & Pathology in Korean Medicine
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    • v.25 no.2
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    • pp.155-162
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    • 2011
  • Sinsuntaeeuljagumdan is a medical book written by Jong-jun Lee, who was an government official in Yonsan-gun period in Chosun dynasty. This book has importance in medical history, as it was the first privately published medical book in early Choson dynasty, and written by an bureaucratic gentry, not by a professional doctor. Three versions of this book remain, among which Sungam version is printed and closest to the original, while Kyoto version is facsimile manuscript of the Sungam version. The contents of the book can be divided into three subsections, i.e. constituents and making instructions, applicable symptoms and adminstration directions, and medical records and episodes. The medical records, of these three sections, are total 8 cases, with a great value as the first ever medical record in korean history.

The Study on the Review of Domestic Laws for Utilizing Health and Medical Data and of Mediation for Medical Disputes (보건의료데이터 활용을 위한 국내 법률검토 및 의료분쟁에 대한 조정 제도 고찰)

  • Byeon, Seung Hyeok
    • Journal of Arbitration Studies
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    • v.31 no.2
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    • pp.119-135
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    • 2021
  • South Korea has the most advanced technology in the Fourth Industrial Revolution era because of its high-speed Internet commercialization. However, the industry is shrinking due to its various regulations in building and its utilization of personal information as big data. Currently, South Korea's personal data utilization business is in its early stages. In the era of the 4th Industrial Revolution, it is difficult for startups to use data. There are various causes here. Above all, legal regulations to protect personal information are emphasized. This study confirms that transactions of personal medical records through My Data can be made. Moreover, it confirms that there is a need for a mediating role between stakeholders. This study lacks statistical access in the process of performing stakeholder roles. However, personal medical records will be traded safely in the future, and new subjects will enter the market. Furthermore, the domestic bio-industry will develop. Through this study, various problems were derived in establishing Medical MyData in Korea. Moreover, it looks forward to continuing various studies in the health care sector in the future.

A Study on the Clinical Case of Shihosamul-tang (柴胡四物湯, Bupleurum Four Substances Decoction) - Focusing on case records (醫案) of KyungBoSinPyun (輕寶新篇, New Treatise of Light Treasure) - (시호사물탕(柴胡四物湯)의 임상 사례에 대한 연구 - 『경보신편(輕寶新篇)』의 의안(醫案)을 중심으로 -)

  • Ku, Minseok;Cha, Wung-Seok;Kim, Namil
    • The Journal of Korean Medical History
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    • v.30 no.1
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    • pp.51-59
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    • 2017
  • Shihosamul-tang (柴胡四物湯, Bupleurum Four Substances Decoction) is a very effective and widely utilized prescription in Korean medicine. However, there has not been a clinical example written in the classical literature of Korean medicine that deals with Shihosamul-tang and the delicate and changeable clinical use of Shihosamul-tang remains unknown. This study tries, for the first time, to show the clinical practice of Shihosamul-tang through review of KyungBoSinPyun (輕寶新篇). KyungBoSinPyun is a medical book containing 143 case records in the tradition of the East Asian practice of describing clinical encounters and the therapies employed. This study examines eight examples of case records within KyungBoSinPyun highlighting use of Shihosamul-tang. The purpose is to understand how Shihosamul-tang is applied in clinical practice compared to the description of Shihosamul-tang in Donguibogam (東醫寶鑑). Different descriptions about the symptoms and transformation methods of the prescription have been found in the eight examples of Shihosamul-tang case records contained in KyungBoSinPyun. This paper concludes that the difference between clinical practice and a typical description in medical books should be overcome by medical virtuosity and the potential for change for each clinical case, which is gained when seeing beyond the text of medical books.

An analysis of unplanned reoperation ('계획에 없던 재수술' 의 분석)

  • Kim, Eun-Gyung;Cho, Sung-Hyun;Kim, Chang-Yup;Oh, Byung-Hee
    • Quality Improvement in Health Care
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    • v.2 no.1
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    • pp.118-124
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    • 1995
  • Background: Clinical indicators are objective measures of process or outcome of patient care in quantitative terms. This study aims to review the medical records of patients who 'return to operating room during the same admission', which is one of the critical clinical outcomes, and describe the result by unplanned reoperation rate. Methods: Computerized patient registry was used for selecting subject conditions. For medical records retrieved, two nurse evaluators identified the presence of explicit reoperation planning in medical records. Results: Overall reoperation rate was 2.8% and unplanned reoperation rate 1.3%. The main category of reoperation cause was the postoperative bleeding. Duration of stay from previous operation to reoperation of the unplanned group, 12.7 days, was shorter than that of the planned(p< .05). The differences did not reach statistical significance in age, sex and length of stay. Conclusion: Results suggested that unplanned reoperation rate was lower than 'threshold' level other institutions had established. However, this result could become comparable only after management of medical records would be improved and risk adjusted.

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A Study on the Medical Records of Heebin Jang in Seungjeongwon Ilgi (『승정원일기』에 기록된 장희빈 의안 관련 연구)

  • Pahng, Sung-Hye;Kim, Namil;Ahn, Sangwoo;Cha, Wung-Seok
    • The Journal of Korean Medical History
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    • v.27 no.2
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    • pp.53-62
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    • 2014
  • The objective of this article is to investigate the medical records written in Seungjeongwon Ilgi ("承政院日記") about Heebin Jang (張禧嬪), who was the mother of King Kyeongjong. She was one of the royal concubines of King Sukjong and later became the queen and then was demoted back to the concubine. The method to do this study was to search the records of Seungjeongwon Ilgi ("承政院日記") from Sukjong 15th year (A.D. 1689) to 20th year (A.D. 1694) on the website databased and serviced by National Institute of Korean History. The results were as follows. According to the website search, Heebin Jang (張禧嬪) suffered from three kinds of diseases. The first was a mastitis right after her delivery. The second was an abscess on the back of her head. The third was a relapse of phlegmturbidity and heat, which was her chronic disease. Also, three features could be found regarding characteristics of Royal medicine. The first was how the queens were taken care of before and after their delivery. The second was who lanced the queen's abscess. The third was how the Royal medicine and people's medicine interchanged.

A Comparative Study of Regional Medical Information Protection Act and Privacy Act (국가별 개인정보보호법 및 의료정보보호법의 비교연구)

  • Bang, Yun-Hui;Rhee, Hyun-Sill;Lee, Il-Hyun
    • The Journal of the Korea Contents Association
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    • v.14 no.11
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    • pp.164-174
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    • 2014
  • The purpose of this study is to explore ways to resolve the conflicting issues that are currently applied in medical Act and medical privacy Act through the comparative Analysis of the Privacy Act and the Medical Information Protection Act foreign. the results run to establish the Public Health Act coming for the protection of health information is a characteristic of many countries, France in Europe, the United States and Canada had been running an independent medical information laws are enacted. Prescribes penalties of up to a fairly systematic method from the case records of patients would not have occurred in the management and implementation of the law and the protection of the author of the book focuses on the subject of medical records and physician records between patient confidentiality and privacy it can be seen that the method defined in. This indicates the need for the establishment of an independent medical information laws to protect all records relating to the patient systematically Korea also.